must be remembered that in typical and fatal cases the large intestine
is the home par excellence of the lesions of chronic catarrh, and that
the lower part of the ileum is often associated in the morbid
processes, but limited areas of the small or large intestine are
affected in mild forms which yield readily to treatment.
Icterus, clay-colored stools, and bile in the urine show that the
catarrh is in the duodenum and involves the opening of the common
bile-duct. The absence of diarrhoea, with flatulence and colics, limits
the area of inflammation to the duodenum. Symptoms of duodenal
indigestion accompany this form of catarrh; the failure of bile to
neutralize the acid chyme impairs the effect of the pancreatic
secretion. Fats are not digested and there is fatty diarrhoea. To this
may be added tenderness in the right hypochondrium, and pain and
oppression in the epigastrium and to the right one hour after eating.
There may be wasting and hypochondriasis.
{712} The lower part of the duodenum below the opening of the
bile-duct, the jejunum, and the ileum can be taken together as forming
the small intestine. Chronic catarrh of the small intestine is attended
with pain about the umbilicus, which comes on immediately or in one
hour after taking food. Tympanitic distension gives a full, rounded
prominence to the abdomen, which is more central than lateral, and
greater below the umbilicus than above it. It is accompanied by a sense
of oppression, which is greater after eating. Inability to digest food
consisting largely of starch or sugar, as well as tardiness in the
digestion of all foods, with resulting loss of flesh, are signs of
intestinal indigestion. There may be no diarrhoea; if there is,
important help to diagnosis can be gained by examining the stools. They
contain undigested or partly-altered meat-fibre and starch-granules,
discoverable only by the microscope. The discharges are soft and pulpy
from an intimate admixture of mucus. To the naked eye no mucus is
visible, but a thin layer under the microscope shows clear islets of
pure mucus, or mucus may only be detected by the adhesion of the
covering-glass to the slide. Bile-stained epithelium and globules of
stained mucus are seen in the liquid stools from catarrh of the small
intestine and of the ascending colon. There is the characteristic
reaction and play of color on testing for bile-pigment. These are
evidences that the stool with the bile has been hurried along the ileum
and colon, and expelled before the transformation in the coloring
matter has had time to take place.[45]
[Footnote 45: "II. Abtheilung, Diagnostische Bemerkungen zur
Localisation der Catarrhe," _Zeitschrift für klinische Medicin_,
Berlin, 1882, iv. p. 223.]
In catarrh of the large intestine there is sensitiveness to pressure
along the line of the colon; the distension of the abdomen is not
uniform, depending upon the prominence of the transverse or descending
colon. The pains are more severe and precede the stools, which are more
frequent and larger than in catarrh of the ileum. The discharges are
pulpy or watery. Globules of mucus are visible to the naked eye, and
mucus is intimately mixed with fecal matter.
If the lower half of the colon is chiefly the seat of the disease, pure
mucus coats the more solid stool and is in its substance. With catarrh
limited to the descending colon scybalæ are imbedded in mucus. From the
sigmoid flexure and rectum larger masses of mucus, without fecal matter
or with it, are expelled. Pure lumps of mucus, mixed or stained with
red blood and without fecal matter, indicate catarrh of the
rectum--proctitis.
(_b_) The stage of the process of inflammation is diagnosed by the
condition of the patient, the course of the disease, and the character
of the stools. As long as there is a pulpy fecal diarrhoea, with no
blood, pus, or fragments of tissue and no marked emaciation or fever,
and with a tendency to improvement under favorable conditions, there is
every reason to believe that there is no ulceration.
In follicular ulceration the course of the disease is essentially
chronic, and is marked by periods of improvement under careful
treatment, with exacerbations and relapses from slight causes of
irritation. There is progressive emaciation and debility, with fever of
hectic character, which is worse in the later stages. The abdomen may
be retracted. The movements are frequent and liquid, and are without
odor or fetid. They {713} contain mucus, glassy-gray or green,
pus-cells imbedded in masses of mucus, blood in small amount, but
sometimes abundant, and shreds of the tissue of the mucous membrane.
This last is an important aid to diagnosis.
The higher the ulcer the less marked is the diarrhoea. The lower its
situation the greater is the frequency of the stools and the more
liable are they to be accompanied by tenesmus and to contain blood and
pus. Toward the last, ulceration is accompanied by rapid emaciation,
fever, sweats, a feeble circulation, a dry tongue, great thirst, and
oedema of the feet and ankles. Death takes place by gradual exhaustion,
more rarely from perforation and peritonitis or from intestinal
hemorrhage.[46]
[Footnote 46: Nothnägel, "Die Symptomatologie der Darmgeschwüre,"
_Klinische Vorträge Volkmann_, No. 200, Aug. 24, 1881.]
Duodenal ulcer is with difficulty recognized during life.[47] The
following are the symptoms which have preceded death from this lesion:
Profuse hemorrhage from the bowel, vomiting of food as well as blood,
icterus, dysphagia, hiccough, oppression in the epigastrium after
eating, attacks of cardialgia with tenderness on pressure in the right
hypochondrium, and sudden death with symptoms of collapse. If these
symptoms follow an extensive burn of the skin, they are easily referred
to a duodenal ulcer.
[Footnote 47: W. L. Loomis, "Perforating Ulcer of Duodenum and Sudden
Death." For two years the patient had suffered with dyspepsia and
epigastric pain after eating, was gouty, and had lost flesh. Autopsy:
atheroma of arteries, beginning cirrhosis of kidneys, walls of stomach
thickened, perforated ulcer one inch below pylorus (_Med. Record New
York_, 1879, vol. xv. p. 188; also _Boston City Hospital Report_, 1882,
p. 374).]
Tuberculous ulcers are distinguished from follicular ulcers by the
history of hereditary predisposition, the existence of pulmonary
tuberculosis, higher fever, and more rapid emaciation and debility.
A cancerous ulcer may be the cause of bloody stools; it is usually
within reach of the finger in the rectum; the mass exercises pressure
upon the prostate, and at times occludes the bowel, causing
obstruction. The cachexia and rapid decline are not seen in catarrhal
ulceration.
PROGNOSIS.--Chronic catarrh of the intestine is most fatal in children.
Among infants artificially fed, when the illness develops and continues
during hot weather, the mortality is very great. Recovery in the young
is rendered less probable if chronic diarrhoea is associated with
rickets, scrofula, or tuberculosis.
If the catarrh in adults is a complication of some previously existing
constitutional disease, as Bright's disease or scurvy, or is connected
with lesions of the liver, spleen, heart, or lungs, there is less hope
of cure. In old persons this disease has a special gravity.
The longer the disease has lasted before treatment is begun, and the
longer it continues without being influenced by treatment, the more
unfavorable will be the prognosis. Discouraging symptoms are an
uninterrupted loss of flesh and strength, lientery, hectic fever,
relapses notwithstanding care in diet, and the signs of
ulceration--blood, pus, and tissue-shreds in the stools, with an odor
of decomposition.
Favorable promises may be based upon a hearty willingness of the
patient to submit to the strictest regimen and to subordinate his life
to the plans of treatment, the absence of other diseases, early
improvement in his general condition and local symptoms under rest and
diet. A {714} complete cure cannot be assumed to exist unless the
patient has passed one or more years without a relapse.
TREATMENT.--As chronic intestinal catarrh is a complication of so many
conditions, the prevention of it becomes a matter of great importance
and of very general application. All rules for preserving
health--temperance in eating and drinking, bathing, exercise, good
ventilation, the avoidance of overwork, both mental and physical--are
so many means for escaping an intestinal catarrh which may present
itself as an indigestion with constipation or as a diarrhoea.
The special liability of infants and children, and to a less extent of
very old persons, and the greater dangers they run, call for the most
careful selection of appropriate diet at these periods of life.
Where there is hereditary predisposition, idiosyncrasy, chronic
diseases of organs, or constitutional diseases, an easily-digested
dietary should be supplemented by precautions against chilling of the
surface by the wearing of flannel underclothing and woollen socks.
The etiology of each case may at once suggest a line of treatment.
Among the causes which point to appropriate measures are--the continued
presence in the bowel of indigestible or undigested food, constant
exposure to cold or to changes of temperature, chronic cardiac disease
and portal congestion from any cause, chronic cachexiæ, as syphilis,
malaria, tuberculosis, or Bright's disease, the crowding together of
individuals in prisons, asylums, etc.
1. The mildest form of intestinal catarrh characterized by intestinal
indigestion and constipation or by the passage of fecal matter more or
less solid, mixed or coated with mucus, is best treated by a diet such
as is advised for intestinal indigestion, bathing with friction,
outdoor life, exercise on horseback or by walking, pleasurable
occupations, and travel. Iron if there is anæmia, and strychnia if
there is a sluggish capillary circulation, with cold hands and feet,
are available and useful in many cases. Massage and the Swedish
movement treatment find useful application in feeble men and in women
who are not strong enough for outdoor exercise. To aid the digestion
the liquor pancreaticus as advised by Roberts, a teaspoonful one hour
and a half to two hours after each meal, with ten to twenty grains of
the bicarbonate of sodium, is, theoretically at least, to be warmly
recommended. The Rockbridge alum water, a small glass three times daily
between meals, has astringency enough for the hyperæmic membrane and is
of good service without increasing constipation.
Purgatives should be avoided as much as possible. An enema of cool
water, not more than a tumblerful, taken each morning after breakfast
if persevered in, may do all that is needed in this direction. If it
fails to empty the bowel completely, a larger enema of warm water--one
pint--holding in solution sulphate of zinc or alum in the strength of
one grain to three or four ounces, can be thrown high up with a rubber
tube once daily. This acts upon the mucous surface, constringes mildly
the congested vessels, and when expelled brings away the retained fecal
matter. These astringent rectal injections offer promise of cure in
many obstinate cases where the colon is chiefly the seat of disease.
Belladonna is advised for cases of this kind in combination with
strychnia for the constipation. Mild laxatives are often necessary.
Bedford mineral water, Hunyadi water, or other salines and the less
active vegetable {715} cathartics, can be given alternately.
Ipecacuanha has had quite a reputation in combination with purgatives
in intestinal catarrh. Aloin pills empty the bowel without much
attendant irritation.
2. The form of catarrh which shows itself in a tendency to diarrhoea
from indiscretions in diet or from exposure to cold must receive
prophylactic treatment. Especially in this form is it important to
improve the activity of the skin by bathing and friction, and to lead a
temperate life in all things, regulating the diet according to the
rules already stated. Tonics are called for in such cases. Fowler's
solution of arsenic (one drop before each meal, Ringer), the
potassio-tartrate or the tincture of the chloride of iron, dilute
sulphuric acid, nitro-muriatic or hydrochloric acid, are efficient in
improving digestive activity or in opposing the anæmia which is nearly
always present. Quinia is indicated in malarial anæmia with a
disposition to loose bowels. Quassia or other vegetable bitters can be
given if the appetite is languid; the bitters are, as a rule, of little
benefit, and may do harm if diarrhoea exists. Strychnia with quassia or
columbo stimulates the appetite and the gastric digestion. When
intercurrent attacks of diarrhoea come on with coated tongue,
flatulence, distress about the umbilicus after eating, bismuth given on
an empty stomach in full doses is serviceable. Small doses of morphia
or of opium in some form can be added to the bismuth if there is much
pain or when the stools are frequent.
In this and in other forms of intestinal catarrh mineral waters are
profitably employed. They are best taken at their sources; and here, as
in the case of sea-bathing, the benefit is largely due to the change of
air and scene and to the more simple mode of life. Any of the
watering-places where alkaline-saline waters or ferruginous waters are
found may be of benefit. A trip to Europe and a stay at Carlsbad will
break up many an obstinate case of chronic abdominal disorder; but
other beneficial waters in Europe are Tarosp, Rohitsch, Marienbad,
Kissengen, and Plombières.
In this country the comfort and conveniences of the summer hotels and
climate are as much to be considered as the chemical composition of the
waters. For milder forms of catarrh with constipation a season at
Saratoga, with a life of temperance there, is a wise procedure. Bedford
Springs, Pa., offer the same advantages in part, but the waters are
best suited to catarrh with constipation. Many of the Virginia springs
benefit health-seekers who do not place too much reliance upon the
virtues of the waters, and who trust to the value of pure air,
exercise, diversion, and rest.
3. All plans of treatment for the more severe form of catarrh with
chronic diarrhoea (follicular enteritis) must be based upon a knowledge
of the lesions. Bearing in mind the alterations in the mucous and
submucous tissues, it is clear that no treatment can be successful
which is not carried out with the most careful attention to details,
and which is not continued for some time after all the symptoms of the
disease have ceased. The complete resolution of hypertrophied glandular
tissue, the scattering of cell-accumulations, and the healing of ulcers
can only be secured in this way. It is best to present the whole case
before the patient, so as to enlist in the task his intelligent
co-operation.
Directions for the guidance of cases of this kind must include every
{716} detail of the patient's life. The question of residence is of
importance to begin with. A cool and dry climate is better than a wet
and warm one, and where other means fail change of climate is sometimes
the only cure. A sea-voyage, a residence in a mountain-region, will
oftentimes promptly and effectually cure an obstinate diarrhoea.
House-drainage and ventilation should be examined into and improved.
The occupation may have developed the disease; in overwork may lie the
origin and the cause of its continuance. Rest from work is therefore in
some instances the one thing needed. In all cases the energies and the
brain should not be overtaxed. The bath to keep the skin active can be
combined with friction. The hot bath, as hot as can be borne, is the
best. It is a stimulant, not a depressant, as is the tepid bath, and it
is safer than the cold bath.
The cold sitz bath or the application of cold compresses diminishes
abdominal plethora, and is wisely advised in strong persons who are not
depressed or chilled by external cold. Sea-bathing is another
hydro-therapeutic measure which is of unquestioned advantage in all
forms of intestinal catarrh.
Permanent baths have been found very serviceable in many chronic
diseases, and there are many reasons for advising them in obstinate
diarrhoeas. There can be no better means for bringing to bear a strong
and continued influence upon the intestinal mucous membrane. The
patient should be kept in the warm bath for one, two, or three weeks,
according to his strength and the effect upon the disease. Systematic
hot bathing under the direction of a physician at Richfield, Sharon,
the Hot Springs of Virginia or Arkansas, is an invaluable aid.
Rest in the recumbent position for cases where the symptoms indicate
marked tissue-alteration is very often the most important part of the
treatment. Rest and diet are alone necessary to cure many cases, and
without these combined means relief is often impossible. The rest
should be absolute, the patient using a bed-pan and lying down all the
time. The contraindications for this method are a slight diarrhoea
which yields to other treatment, and loss of strength and appetite from
the deprivation of air and exercise.
If rest is not advisable, or does no good after a fair trial of two to
four weeks, outdoor life in fair weather by driving or walking slowly
can be suggested. A long drive will bring back a diarrhoea which has
taken many weeks to relieve.
The rules for diet must be clearly given and strictly enforced. An
exclusive milk diet should have a trial in every case. Skimmed milk can
be taken in larger quantities and with less repulsion, and is therefore
to be preferred. The exclusive milk diet can be varied with buttermilk,
koumiss, or wine-whey; and fruit-juices, as orange-juice, lime-juice,
or tamarind-water, please the patient without doing harm. In the case
of adults as well as children the milk is made more digestible by
diluting it with barley- or rice-water or by adding transformed
farinaceous food to milk in the form of Mellin's food and other foods
of this class.
Animal broths, as chicken-soup and beef-tea, are well digested if
properly made and given in small quantities. Raw meat scraped, beef or
mutton rare and thoroughly masticated, the breast of poultry, game,
broiled fish, raw oysters, raw or very slightly boiled eggs, or
sweetbread, are foods from which selection can be made to add variety
to the dietary. {717} Saccharine, starchy, and fatty foods are to be
given as little as possible. Vegetables may be added to the list as the
condition improves. Rice and fine hominy (grits) are to be thought of
first, as being easily digested and nourishing. Good wine in moderation
is not hurtful; the red wines diluted with water are the best, but good
port, tokay, and whiskey well diluted find application in particular
cases.
Whatever food be given, it should be taken in the quantities and at
hours prescribed by the physician, who by careful inspection of the
stools judges of the necessity of changes in his regulations and of the
success of his treatment.
The further treatment of chronic diarrhoea has for its object by the
aid of drugs to change the anatomical state of the mucous membrane.
Manifestly, the choice depends upon the state of this tissue. In the
earlier stages the increased vascularity and hypersecretion call for
mild astringents or for medicines which are believed empirically to
oppose these conditions. When drugs can be dispensed with, it is better
to do so; they should always be made subordinate to the careful regimen
already described.
Bismuth in large doses (ten to thirty grains) is a safe and efficacious
remedy in this stage. Nitrate of silver in pill form (one-sixth to
one-fourth of a grain) has the endorsement of Wm. Pepper and many other
practitioners. It should be continued for two or three weeks at least,
but it may be given in small doses during several months, with
intermissions, without danger of silver staining.[48]
[Footnote 48: A case is recorded of silver staining of the skin after
four weeks' administration (Woodward, _op. cit._, p. 780).]
A routine administration of any drug or class of drugs is
reprehensible, and from the numerous remedies which are advocated in
chronic diarrhoea selection can be made for trial in the course of
intractable cases. The list would include sulphate of copper
(one-fourth to one-half a grain), the liquid preparations of iron
(liquor ferri nitratis, tinct. ferri chloridi), dilute nitric and
sulphuric acids, gallic acid and other vegetable astringents, oxide or
sulphate of zinc, alum, precipitated phosphate of calcium, salicin,
corrosive sublimate (1/100 gr. every hour), the Indian bael-fruit, etc.
No remedy should be abandoned until it has been continuously given for
one or more weeks.
The Rockbridge (Va.) alum water is markedly astringent, is not
unpleasant, and may be used as a substitute for water with advantage.
In fact, there is no better way of introducing in quantity a mild
astringent into the intestine than by the drinking of this water.
Cold-water rectal irrigation has a sedative and astringent influence,
and when properly used is of great advantage to both children and
adults.[49] The patient should be placed in the proper position, and
the water made to enter the rectum as high up as possible. The number
of stools lessens almost immediately after this treatment, peristalsis
being inhibited thereby.
[Footnote 49: A long rectal rubber tube, such as advised by
Surgeon-General Wales, U.S.N., serves this purpose well.]
To the water used in irrigation astringents may be added in small
doses. Sulphate of zinc, sugar of lead, or alum may be given in this
way in the strength of one grain to four or six ounces of water. This
{718} method of treatment promises more and is more rational than the
internal administration of drugs.
Opium and its preparations should be avoided except to control frequent
or watery discharges or to relieve pain, but it is not often that this
is called for if wiser measures are first employed. Any of the remedies
spoken of may be given in the form of suppositories with greater
advantage often than by the mouth.
In that more severe class of cases called follicular ulceration, in
which the follicles are known to be ulcerated from a prolongation of
the illness, the obstinacy of the diarrhoea, the character of the
discharges, and the effect upon the general health, other measures are
to be adopted. The diet should be most strictly regulated and the
digestive power of the patient carefully studied. Cod-liver oil is
added with advantage to other foods if there is a lack of nutrition.
Aids to gastric digestion are called for.
The intestinal lesion is to be reached through the stomach or the
rectum. Nitrate of silver in small doses is more especially applicable,
and is to be preferred to all other drugs in this stage. It is to be
given in small doses and for several weeks.
Turpentine and copaiba have something in their favor in ulceration.
Ergot has been suggested, and where there is much hemorrhage from the
bowel may be prescribed.
Irrigations with solutions of nitrate of silver seem to be a direct and
certain remedy in cases where ulceration has existed for a long time.
Two and a half to three pints of distilled water, holding in solution
five grains of nitrate of silver, should be thrown up the rectum as
high as possible with a rubber tube; the effort should be made to
secure immediate exit to the fluid. This procedure is to be repeated
after the bowels are moved--once every day or every other day if the
rectum becomes irritable.[50]
[Footnote 50: See case reported by the writer to the Medical Society of
the District of Columbia, and published in the _Maryland Medical
Journal_, March 15, 1883, p. 562.]
{719}
CHOLERA MORBUS.
BY W. W. JOHNSTON, M.D.
SYNONYMS.--Cholera nostras, Sporadic cholera, European or English
cholera, Spasmodic cholera, Cholera biliosa, Passio cholerica,
Cholerhagia, Trousse-galant, Die Gallenruhr, Brechruhr.